Leave Request Form

LEAVE REQUEST/AUTHORIZATION

NAVCOMPT FORM 3065 (3PT) (REV. 2-83)

1. DATE OF REQUEST
2. FOR ADMIN. USE ONLY

APPROVAL OF THIS LEAVE IS

NOT VALID WITHOUT CONTROL NO,
3. SSN
4. NAME (Last, First, MI)
LEAVE CONTROL NO.
5. PAY GRADE
6. SHIP/STATION
7. DEPT/DIV
10. TYPE LEAVE
8. DUTY
9. DUTY PHONE
SECTION
12. MODE OF TRAVEL
FOR USE OUTUS ONLY
REGULAR
SICK
SEPARATION
EMERGENCY
OTHER
RETIREMENT
13. DAYS REQUESTED
14. FROM (Hour, Date) (YYMMDD)
17. LEAVE BALANCE
18. LEAVE USED THIS FY
DAYS AS OF
SEE REVERSE FOR

PRIVACY ACT
STATEMENT
INSTRUCTIONS FOR COMPLETING THIS FORM ARE

ON THE REVERSE OF PART 3.
11a. Leaving Area of PERMDUSTA

AIR
YES
NO
11b. Taking Leave INCONUS
CAR
YES
NO
15. TO (Hour, Date) (YYMMDD)
16. NORMAL WORKING HOURS
DAY OF DEPARTURE:

FROM:
19. LEAVE PHONE
BUS
TRAIN
TO:
DAY OF RETURN:
() -
FROM:
TO:
21. RATION STATUS (Enlisted)
20. LEAVE ADDRESS
COMMUTED RATIONS (COMRATS)

Meal Pass No.
Entitled to EDF meals except during
periods of leave
I CERTIFY THAT I HAVE SUFFICIENT FUNDS TO COVER THE COST OF ROUND TRIP TRAVEL. I
UNDERSTAND THAT SHOULD ANY PORTION OF THIS LEAVE, IF APPROVED, RESULT IN MY
TAKING MORE LEAVE THAN I CAN EARN ON MY CURRENT UN-EXTENDED ENLISTMENT OR
CURRENT ACTIVE DUTY OBLIGATION, MY PAY WILL BE CHECKED FOR SUCH EXCESS LEAVE.
RECOMMENDED
YES
NO
YES
NO
YES
NO
YES
23. APPROVED
22. SIGNATURE OF APPLICANT
DATE
NO
DISAPPROVED
24. COMMENTS/REMARKS
CDO Pager: 241-7795

CDO CELL: 564-4446
Q-DECK: 791-2613
25. SHIP OR STATION (Including telegraphic address)
NSGA Fort Gordon
Fort Gordon, GA 30905
COMM: (706) 791-2613
DSN: 780-2613
26. REPORT ON EXPIRATION OF LEAVE TO (if other than block 25)
DEPARTED ON LEAVE
27a. HOUR
27b. DATE (*YYMMDD)
RETURNED FROM LEAVE

28a. HOUR
28b. DATE (*YYMMDD)
GRANTED EXTENSION OF LEAVE ENDING

29a. HOUR
29b. DATE (*YYMMDD)
27c. OODS SIGNATURE
28c. OODS SIGNATURE
29c. OODS SIGNATURE
IN CONSIDERATION OF THE MEMBERS COMPLETION OF A

FULL WORKDAY (AS DEFINED IN MILPERSMAN, NAVPERS
15560) ON THE DAYS OF DEPARTURE AND RETURN, THE
INCLUSIVE DAYS SHOWN ARE CORRECT AND PROPER FOR
CHARGING AS LEAVE.
I CERTIFY THAT THE ABOVE IS CORRECT
AND PROPER TO THE BEST OF MY
KNOWLEDGE.
30. INCLUSIVE
LEAVE PERIOD
TO BE
CHARGED
FIRST:
(YY)
32. CERTIFYING OFFICERS TYPED NAME/RANK/TITLE
LAST:
(MM)
(DD)
(YY)
(MM)
(DD)
31. NO. OF
DAYS
33. CERTIFYING OFFICERS SIGNATURE
FORWARD THIS COPY TO PERSONNEL OFFICE VIA COMMAND ONLY ON COMPLETION OF LEAVE.
S/N 0104-LF-703-0656
PART 1
INSTRUCTIONS FOR COMPLETING THE LEAVE REQUEST PORTION OF THIS FORM

1. Completion of this form must be in ballpoint or typewriter. The form must be completed in triplicate with all copies legible.
2. Print or type the appropriate date in block 1 and 3 through 21. Leave block 2 blank.
3. When completing blocks 14 and 15, follow these rules:
a. Block 14 - The hour for starting leave may not be prior to the end of your normal workaday if leave starts on a workday. Of leave
starts on a non-workday, the starting hour may be 0001 if not contrary to command policy.
b. Block 15 - The hour for ending leave may not be later than the beginning of your normal workday if the day of return is a workday.
If leave ends on a non-workday the ending hour may be 2400 if not contrary to command policy.
4. Block 16 requires the following information:
Normal working hours for day of departure

Normal working hours for day of return
If day of departure is not a workday, enter NONE
5. Information required in blocks 17 and 18 may be obtained from Block 59 of your latest Leave and Earnings-Statement or youre your
activitys Commanding Officers Leave Listing.
6. You are advised that you must immediately return your original leave authorization to the appropriate office designated by your
command upon return from leave.
PRIVACY ACT STATEMENT

FOR
NAVCOMPT 3065
LEAVE REQUEST/AUTHORIZATION
This statement is provided in compliance with the provisions of the Privacy Act of 1974 (PL 93-579), which
require that Federal agencies must inform individuals who are requested to furnish information about themselves
as to the following facts concerning the information requested.
1. AUTHORITY: Title 10 and 37 USC
2. PRINCIPAL PURPOSE(S): To authorize military leave of absence.
3. ROUTINE USE(S): To deduct leave taken from members accrued leave balances. To pay leave rations to
enlisted members.
4. MANDATORY OR VOLUNTARY DISCLOSURE: voluntary. If the member does not request a specific
period of leave or furnish his leave address, leave is not granted.

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LEAVE REQUEST/AUTHORIZATION

NAVCOMPT FORM 3065 (3PT) (REV. 2-83)

2. FOR ADMIN. USE ONLY

APPROVAL OF THIS LEAVE IS

4. NAME (Last, First, MI)

LEAVE CONTROL NO.

10. TYPE LEAVE

12. MODE OF TRAVEL

FOR USE OUTUS ONLY

13. DAYS REQUESTED

14. FROM (Hour, Date) (YYMMDD)

17. LEAVE BALANCE

18. LEAVE USED THIS FY

SEE REVERSE FOR

INSTRUCTIONS FOR COMPLETING THIS FORM ARE

11a. Leaving Area of PERMDUSTA

19. LEAVE PHONE

20. LEAVE ADDRESS

COMMUTED RATIONS (COMRATS)

22. SIGNATURE OF APPLICANT

CDO Pager: 241-7795

26. REPORT ON EXPIRATION OF LEAVE TO (if other than block 25)

RETURNED FROM LEAVE

GRANTED EXTENSION OF LEAVE ENDING

27c. OODS SIGNATURE

28c. OODS SIGNATURE

29c. OODS SIGNATURE

IN CONSIDERATION OF THE MEMBERS COMPLETION OF A

32. CERTIFYING OFFICERS TYPED NAME/RANK/TITLE

33. CERTIFYING OFFICERS SIGNATURE

INSTRUCTIONS FOR COMPLETING THE LEAVE REQUEST PORTION OF THIS FORM

Normal working hours for day of departure

PRIVACY ACT STATEMENT

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